Your out-of-pocket maximum is the most you’ll pay for covered, in-network care in a plan year. Once you hit it, the plan pays 100% of covered care for the rest of the year.
A simple example
Your out-of-pocket maximum is $6,000. Between your deductible, copays, and coinsurance, you’ve paid $6,000 this year. Every additional covered, in-network service for the rest of the year costs you $0.
Why it matters to you
This is your financial safety net — the worst-case ceiling for covered care in a year. When you’re comparing plans, it tells you how bad a truly bad year could get.
Good to know
- Premiums don’t count toward your out-of-pocket maximum.
- Out-of-network care usually doesn’t count either — another reason to stay in-network.
- It resets each plan year, along with your deductible.
Definition: HealthCare.gov — Out-of-pocket maximum. See also Deductible and Copay & coinsurance.
Educational use only. This content is general health and cost information — not medical advice, diagnosis, or treatment, and not financial, legal, or insurance-coverage advice. Specifics vary by plan and situation. Talk with a qualified clinician about your care and verify coverage with your insurer or provider. In an emergency, call 911.